1. Serious Case Review Briefing Child G1

2. Purpose of a Serious Case Review: Review:
Establish what lessons are to be learnt about the way in which professionals and organisations work together to safeguard children.
Identify the lessons, how and in what timescales they will be acted upon.
Improve multi-agency working to better safeguard and promote the welfare of children.

3. Criteria for Serious Case Reviews: Review:
A Serious Case Review (SCR) is one where:
a) Abuse or neglect of a child is known or suspected; and
b) Either (i) the child has died; or (ii) the child has been seriously harmed and there is cause for concern as to the way in which the authority, the Board partners of other relevant persons have worked together to safeguard the child
From Working Together 2015
Regulation 5 of the Local Safeguarding Children Boards Regulations 2006
The purpose of these reviews is to identify improvements which are needed and to consolidate good practice. LSCBs and their partner organisations should translate the findings from reviews into programmes of action which lead to sustainable improvements and the prevention of death, serious injury or harm to children. (Working Together, 2013:66)

4. Learning and improvement not blame.
A is not:
A Serious Case Review is not: Review:
An enquiry into:
how a child was harmed; or
which agency or individual professionals were culpable.
Learning and improvement not blame.

5. A is not: Who is G1?Review:
G1 was a 4 year old child, who was taken to the Paediatric Emergency Department in 2015.
Her mother reported she had fallen the night before and had hurt her ankles.
On admittance, it was identified that she had two broken ankles and a significant number of other current and past injuries, identified as non-accidental.
Child G1 was made subject to an Emergency Protection Order, followed in due course by a Care Order.
Both G1 and a sibling were placed in foster care.

6. Key Lines of Enquiry: Review:
Time period from initial contact with statutory agencies February 2013 to admission to hospital and appropriate safeguarding June 2015.
Quality of assessments
Barriers to appropriate information sharing
Professional responses to mother attributing G1’s concerning behaviours to historic Domestic Abuse
SCR Team agreed the key lines of enquiry

7. Key Lines of Enquiry continued:
Response to concerning behaviours and disclosures of abuse in school settings
Effectiveness of multi-agency working around this family and associated complexities
How medical information is shared across agencies when a child has presented on numerous occasions
To consider risk management when a new adult comes into a family
SCR Team agreed the key lines of enquiry

8. The Voice of the Child: Review:
May 2014: Section 7 report is prepared for the Family Court
The Voice of the Child: Review:
The review identified fundamental weaknesses: in communication with Child G1:
Child G1’s words and actions were overshadowed by the parents’ narrative.
Repeated verbal disclosures made against father and mother.
Lack of Social Work awareness of context of discussions with child - no understanding of building trust or a ‘safe space’
Lack of awareness of non-verbal communication
Lack of tenacity in following up comments from G1 to increase understanding - a sense it was ‘ better not to ask too many questions’

9. The Voice of the Child: Review:
Recording the ‘Voice of the Child’ is meaningless if that voice is not heard, understood and taken seriously
Introduction of ‘Signs of Safety’ model helps with materials to work with children - awareness needs to be developed

10. Review findings: Review:
Child G1’s injuries were caused by adults who should have been nurturing and caring; they deliberately and over a long period, put barriers in the way of services who could have intervened to provide protection.
There were fundamental weaknesses in the safeguarding system which meant what was happening to Child G1 failed to be understood, or responded to, for far too long.
Over 2 years, opportunities were missed when good investigation and assessment practice could have led to an understanding that this child was at risk of significant harm.

11. Review findings: Review:
Conclusions:
Review findings: Review:
A cumulative effect of repeated misunderstanding of Child G1’s experience reinforced subsequent misconceived responses as to what was happening.
Finally, but possibly most importantly, there were fundamental weaknesses in the way key professionals were able to hear and listen to what Child G1 was trying to tell them.

12. Good Practice: Review:
What worked well:
Good Practice: Review:
Both schools identified and flagged concerns
CP medical and implementation of recommendations arising from it
Information sharing between nursery and primary school was good resulting in swift involvement of school counsellor
Swift intervention when non-accidental injuries were identified, with interim care order to safeguard both child G1 and sibling

13. Learning Points: Review:
Disclosures of abuse by children whether made directly or indirectly through their behaviour, must always be given the highest priority and fully investigated.
Services need to ensure their systems and staff are able to recognise and intervene to halt the cumulative effect of repeated injuries or other concerns.
The development and maintenance of quality fully skilled staff, supported by the organisation to undertake work at the front door and to prepare high quality social work assessments should be afforded the highest priority by Children’s Social Care.

14. Learning Points: Review:
Robust information gathering for assessment particularly in relation to the history of all members of a household should be considered a basic requirement of practice.
A culture of challenge and reflection must be developed to enable front line practitioners to question what they are told; allowed to admit they might be wrong; and routinely give consideration to alternative hypotheses. Escalation.
Where management oversight has lost focus on quality, outcomes such as those experienced for Child G1 risk being repeated.

15. Learning Points: Review:
The authority needs to satisfy itself that front line staff have well developed skills in understanding and communicating with children
Medical assessments that an injury is ‘compatible with’ an explanation should not be confused with a judgement that something is not non accidental. Think: Substantiated/not substantiated/not proven.
How confident can the authority be about the quality of S7 reports and the attention paid to quality assuring these reports? Consideration to be given to joint working with CAFCASS to develop quality markers and training for S7 reports.

16. Learning Points: Review:
Where decisions about children’s needs or risks are reliant on a reassurance from, or belief that other agencies are taking action, this should be subject to a system of review.
Is there a need for professional development across agencies on burns and physical abuse?
Use of labels and ‘diagnoses’ such as trauma or good attachment, need to be underpinned by robust evidence and challenge.

17. Recommendations and Challenges:
The Board to seek evidence from all partners as to how they provide sensitive services to the victims of domestic abuse, whilst maintaining appropriate caution when allegations are not yet proven
The Board to examine the effectiveness of its escalation policy across agencies.
The Board to consider developing a clear and shared understanding between Children’s Social Care, the Police and Community health regarding the scope of Child Protection Medicals, their contribution to S47 enquiries and how recommendations are put in place.

18. Recommendations and Challenges:
The Board to share this Review with the relevant Designated Family Judge with a view to achieving further learning.
Greater Manchester Police to provide evidence to the Board that appropriate links are in place between the Serious Sexual Offences Unit and the Police Protection Unit (PPU)

19. Any questions / comments
Finally:
Finally:
Any questions / comments
Thank you